<div class="form_container" style="width: 760px;">		 
	<table cellpadding="0" cellspacing="0" width="500px">
		<tr>
			<td class="label">{translate}Full name{/translate}</td>
			<td class="field">{$name}</td>
			<td class="label">{translate}Patient's ID{/translate}</td>
			<td class="field" style="text-align: left;">{$code}</td>
		</tr>
		<tr>
			<td class="label">{translate}Address{/translate}</td>
			<td colspan="3" class="field">{$address}</td>
		</tr>
		<tr>
			<td class="label">{translate}Time collected fee{/translate}</td>
			<td colspan="3" class="field">{$paymentTime}</td>
		</tr>
		
		<tr>	
			<td class="label">{translate}Must collect{/translate}</td>
			<td colspan="3" class="field">{$patientPayment}</td>					
		</tr>		
		<tr>
			<td class="label">{translate}Real payment{/translate}</td>
			<td colspan="3" class="field"><input id="real_payment" type="text" value="{$realPayment}"></td>
		</tr>
		<tr>
			<td class="label">{translate}Description{/translate}</td>
			<td colspan="3" class="field">
				<textarea rows="2" cols="25" id="note">{$note}</textarea>			
			</td>
		</tr>
		<tr>
			<td>
				<span id="status_message" style="color: green; font-style: italic"></span>
			</td>
			<td colspan="3" align="right">
				<input id="turn_back" class="button_link" type="button" value="{translate}Back{/translate}" onclick="javascript:turnBack('detail_content', 'ticket_content')">
				<input id="save_payment" class="button_link" type="button" value="{translate}Save{/translate}" onclick="javascript:savePayment({$paymentCollectionId})">
			</td>
		</tr>		
	</table>
</div>
